=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710533054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A JOURNEY RENEWED COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2019
-----------------------------------------------------
Last Update Date | 08/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 UPTOWN BLVD FL 2
-----------------------------------------------------
City | CEDAR HILL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75104-3527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-799-1038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 UPTOWN BLVD FL 2
-----------------------------------------------------
City | CEDAR HILL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75104-3527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-799-1038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KYSHEENNA LEWIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-799-1038
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------